Focused SOAP Note
Task: Assessing, Diagnosing, and Treating Dementia, Delirium, and Melancholy
Picture Credit score: Getty Photographs
With the prevalence of dementia, delirium, and despair within the rising geriatric inhabitants, you’ll probably take care of aged sufferers with these issues. Whereas many signs of dementia, delirium, and despair are related, it will be significant that you’ll be able to establish these which are totally different and correctly diagnose sufferers. A analysis of one in every of these issues is usually tough for sufferers and their households. In your function as a sophisticated apply nurse, you have to Help sufferers and their households handle the dysfunction by facilitating vital remedies, assessments, and follow-up care.
To organize:
• Assessment the case examine supplied by your Teacher. Mirror on the best way the affected person introduced within the case, together with whether or not the affected person is likely to be presenting with dementia, delirium, or despair.
• Mirror on the affected person’s signs and facets of issues which may be current. What distinct signs or elements would lead you to a analysis of dementia, delirium, or despair?
• Think about the way you may assess, carry out diagnostic checks, and suggest drugs to deal with sufferers presenting with the signs within the case.
• Entry the Focused SOAP Note Template on this week’s Assets.
The Task:
Full the Focused SOAP Note Template supplied for the affected person within the case examine. Remember to handle the next:
• Subjective: What was the affected person’s subjective criticism? What particulars did the affected person present relating to their historical past of current sickness and private and medical historical past? Embrace a listing of prescription and over-the-counter medicine the affected person is presently taking. Examine this listing to the American Geriatrics Society Beers Standards®, and take into account various medicine if applicable. Present a Assessment of methods.
• Goal: What observations did you be aware from the bodily Assessment? What had been the lab, imaging, or useful assessments outcomes? How would you interpret and handle the outcomes of the Mini-Psychological State Examination (MMSE)?
• Assessment: Present a minimal of three differential diagnoses. Checklist them from prime precedence to least precedence. Examine the diagnostic standards for every, and clarify what guidelines every differential in or out. Clarify you essential considering course of that led you to the first analysis you chose. Embrace pertinent positives and pertinent negatives for the particular affected person case.
• Plan: Present an in depth therapy plan for the affected person that addresses every analysis, as relevant. Embrace documentation of diagnostic research that will probably be obtained, referrals to different healthcare suppliers, therapeutic interventions, training, disposition of the affected person, caregiver help, and any deliberate follow-up visits. Present a dialogue of well being promotion and illness prevention for the affected person, making an allowance for affected person elements, previous medical historical past (PMH), and different threat elements. Lastly, embrace a mirrored image assertion on the case that describes insights or classes discovered.
• Present a minimum of three evidence-based peer-reviewed journal articles or evidenced-based tips, which relate to this case to help your diagnostics and differentials diagnoses. Ensure they’re present (not more than 5 years outdated) and help the therapy plan in following present requirements of care. Comply with APA seventh version formatting.
Focused SOAP Note
Affected person Info:
Initials: Ms. W Age: 67 Intercourse: Feminine Race: African American
S (subjective)
CC (chief criticism): Considerations of forgetfulness.
HPI (historical past of current sickness): Ms. Washington is a 67-year-old African American feminine who is dropped at your workplace by her daughter with issues of “forgetfulness.” She has lived together with her daughter for four years now, and her daughter studies noticing she asks the identical questions even after they’ve been answered. She even studies her mother getting misplaced in Walmart just lately. Ms. Washington has lived together with her daughter since dropping her husband of 57 years, about four years in the past. Her daughter states her mom is a retired instructor and often very astute however notices extra forgetfulness. In response to Ms. Washington’s daughter, Angela, her mother has been demonstrating elevated forgetfulness of more moderen issues however can simply recall historic moments and occasions. She additionally studies that typically her mother has problem “discovering the suitable phrases” in a dialog, after which will shift to a wholly totally different line of dialog. She additionally stated her mom will “chuckle off” issues when she forgets necessary appointments and/or turn into upset or essential of others who attempt to level this stuff out.
Present Medicines:
• Amlodipine 10mg every day
• HCTZ 12.5mg every day
• Multivitamin every day
• Atorvastatin 40mg every day
• Alendronate 70mg orally as soon as every week
Allergic reactions: Penicillin: rash, Lisinopril: cough.
PMHx: Hypertension, Hyperlipidemia, Osteoporosis
Soc and Substance Hx: Lives with the daughter since dropping her husband of 57 years four years in the past. She is a retired instructor. No historical past of tobacco or alcohol use. She has lived with the daughter for four years.
Fam Hx: She has been married for 57 years. Her husband died four years. The reason for loss of life is unknown. The well being of the daughter is insignificant.
Surgical Hx: No historical past of prior surgical procedures.
Psychological Hx: The affected person has a historical past of forgetfulness. The daughter recollects she just lately bought misplaced in Walmart. Ms. Washington scores 18 out of 30 with major deficits in orientation, registration, consideration and calculation, and recall.
Violence Hx: No historical past of private, house, or sexual violence.
Reproductive Hx: She is 67 years and previous menstruating age. No historical past of sexual activity because the loss of life of her husband.
ROS (Assessment of signs):
• Common: No weak point, fever, chills, physique weight reduction or acquire.
• Head: No historical past of trauma or influence.
• EENT (eyes, ears, nostril, and throat): No visible loss or double imaginative and prescient, no listening to loss or discharge, no nasal discharge or congestion, and no sore throat.
• Cardiovascular: No historical past of edema, ache, or strain.
• Respiratory: No shortness of breath.
• Gastrointestinal: No nausea, vomiting, belly ache, diarrhea, or constipation.
• Genitourinary: No historical past of nocturia, dysuria, breast or cervical most cancers. Postmenopausal.
• Musculoskeletal: No historical past of joint or muscle ache, falling or osteoporosis.
• Neurological: No historical past of headache, dizziness, or numbness.
• Hematologic: No historical past of bleeding or anemia.
• Lymphatics: No enlarged nodes. No historical past of splenectomy.
• Psychiatric: No historical past of despair, nervousness, or hallucinations. Affected person has a latest historical past of forgetfulness.
• Endocrinologic: No historical past of diabetes, warmth or chilly intolerance.
• Reproductive: Postmenopausal. No vaginal discharge.
• Allergic reactions: Penicillin: rash, Lisinopril: cough.
O (goal)
Bodily examination:
Common: Ms. Washington is a 67-year-old feminine who’s alert, cooperative with in the present day’s scientific interview. Her eye contact is honest. Speech is evident and coherent however tangential at instances. She makes no uncommon motor actions and demonstrates no tics. She denies any visible or auditory hallucinations. She denies any suicidal ideas or ideations. She is alert and oriented to particular person, partially oriented to position however is disoriented to time and place. (She reported that she thought was headed to work however “wound up right here,” referring to your workplace, at which level she begins to chuckle it off.) She denies any falls or ache.
Important indicators: 98.2 124/74 HR-72 20
Common: A&O *three NAD and appropriately dressed.
HEENT: Intact facial sensation. Pupil equal and round and reactive to mild. Ears are symmetrical and no discharge. Nostril are symmetrical and no nasal polyps. No erythema on the throat. Neck is supple with no tracheal deviation.
Chest/Lungs: CTA AP&L.
Coronary heart/Peripheral Vascular: RRR and not using a murmur, rub, gallop, pulses +2.
Stomach: Diffuse, or rebound.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetric muscle improvement and no falls reported.
Neurological: CN I-IV grossly in intact in addition to ache sensation intact
Pores and skin: No bruises, plaques, or hemorrhage.
Diagnostic outcomes:
1. CXR—no cardiopulmonary findings. WNL
2. CT head—diffuse Cerebral Atrophy
Ms. Washington scores 18 out of 30 with major deficits in orientation, registration, consideration and calculation, and recall. The rating suggests reasonable dementia.
A (Assessment)
Differential diagnoses:
F03. 90 Average dementia
Dementia is a gaggle of signs that have an effect on reminiscence, considering patterns, and social skills that intervene with the every day life actions of a person. One of many main indicators of dementia is reminiscence loss (Lamb et al., 2018). Reminiscence loss impacts the flexibility to partake in every day actions. Though there is no such thing as a treatment for dementia, drugs and remedy can stop deterioration of the situation (Lamb et al., 2018). Sufferers require instant therapy to boost their capability to carry out every day actions.
G30. 9 Alzheimer’s illness, unspecified
Alzheimer’s illness is a degenerative that disables the nervous system resulting in dementia or reminiscence lack of latest actions. The illness could cause loss of life or incapacitation (Weller & Budson, 2018). The reason for Alzheimer’s illness shouldn’t be recognized though scientists argue that it’s a results of a mixture of ailments. The illness can happen in numerous ranges together with Early-Onset, Late-Onset, and Familial (Weller & Budson, 2018). One of many drugs accredited for Alzheimer’s illness is Aducanumab. The remedy is used to scale back amyloid plaques which are related to the illness.
G20 Parkinson’s illness
Parkinson’s illness is a situation that begins by affecting the bodily elements of the physique inflicting shakiness, stiffness and strolling problem (Ball et al., 2019). The situation deteriorates to trigger cognitive challenges inflicting forgetfulness and problem in focus (Ball et al., 2019). The illness can worsen to trigger dementia. The situation results in profound reminiscence loss and problem in sustaining relationships.
F32. 9 Main depressive dysfunction, single episode, unspecified
Main depressive dysfunction causes persistent disappointment and lack of curiosity in every day actions (Kennis et al., 2020). Scientific despair causes an have an effect on in how folks really feel, assume, or behave. Melancholy is related to forgetfulness and confusion (Kennis et al., 2020). Sufferers with despair can overlook primary points similar to instructions. It causes an impact within the movement of a dialog.
P (plan)
The affected person has a psychological drawback that requires each a mixture of medical and non-medical circumstances. Donepezil (Aricept) is the frequent therapy for various phases of dementia (Lamb et al., 2018). Rivastigmine (Exelon) is accredited for therapy of gentle to reasonable ranges of the illness. The affected person ought to take the remedy and report after two weeks for additional analysis. Psychotherapeutic interventions are vital to Help the affected person perceive emotions of disappointment or anger and prescribe remedy to handle the illness (Lamb et al., 2018). The main focus of the therapy is to handle the modifications in temper and habits.
The affected person can be a part of a help group for different aged folks. The help teams will Help the affected person to know different persons are going by way of related incidents (Lamb et al., 2018). The help will present cushion for the affected person to handle the situation successfully.
The affected person ought to come again for Assessment after two weeks. It is going to be necessary for the sister to take precaution to make sure the mom shouldn’t be misplaced within the public buildings once more. The daughter ought to monitor the habits to establish any modifications.
Reflection
The case examine exhibits that sufferers can have totally different signs. A practitioner has a accountability to supply care to the affected person utilizing skilled requirements. It’s vital to handle the sufferers by finishing up an intensive Assessment. One of many observations is that the affected person may very well be affected by the lack of the husband. There isn’t any historical past of psychological sickness within the household and the situation has been deteriorating because the loss of life of the husband. Acceptable therapy interventions are essential within the take care of the affected person. The affected person requires social help similar to an individual who can accompany her to the clinic or public locations similar to grocery store. Early interventions of the situation will enhance the standard of lifetime of the affected person and forestall adversarial outcomes.
References
Ball, N., Teo, W. P., Chandra, S., & Chapman, J. (2019). Parkinson’s illness and the surroundings. Frontiers in neurology, 10, 218.
Kennis, M., Gerritsen, L., van Dalen, M., Williams, A., Cuijpers, P., & Bockting, C. (2020). Potential biomarkers of main depressive dysfunction: a scientific Assessment and meta-analysis. Molecular psychiatry, 25(2), 321-338.
Lamb, S. E., Sheehan, B., Atherton, N., Nichols, V., Collins, H., Mistry, D., … & Lall, R. (2018). Dementia And Bodily Exercise (DAPA) trial of reasonable to excessive depth train coaching for folks with dementia: randomised managed trial. bmj, 361.
Weller, J., & Budson, A. (2018). Present understanding of Alzheimer’s illness analysis and therapy. F1000Analysis, 7.
